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ICD-10-CM guidelines I.C.21.c.4 states, "Personal history codes explain a patient's past medical
condition that no longer exists and is not receiving any treatment, but that has the potential for
recurrence, and therefore may require continued monitoring." Which of the following
conditions, when documented in the past medical history, should a documentation specialist
query the provider regarding?
I. Dementia
II. Lung Cancer
III. Diabetes
IV. Heart Failure
A. I, II, and III
B. II, III, and IV
C. I, III, and IV
D. I, II, III, and IV - iD. I, II, III, and IV
*CMS considers the following conditions as chronic conditions:
Alcohol abuse
Alzheimer's disease and related dementia
Arthritis (osteoarthritis and rheumatoid)
,Asthma
Atrial fibrillation
Autism Spectrum Disorders
Cancer (Breast, Colorectal, Lung, and Prostate)
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Depression
Diabetes
Drug Abuse/Substance Abuse
Heart failure
Hepatitis (Chronic viral B & C)
HIV/AIDS
Hyperlipidemia (high cholesterol)
Hypertension (high blood pressure)
Ischemic heart disease
Osteoporosis
Schizophrenia and other psychotic disorders
Stroke
When any of these conditions are listed in the past medical history, the documentation
specialist should query the provider as these are chronic conditions and are not likely to be
resolved
A 26 year old gravida 2 para 1 female has been spotting and has been on bed rest. She awoke
this morning with severe cramping and bleeding. Her husband brought her to the hospital. After
examination, it was determined she has an incomplete early spontaneous abortion. She is in the
12th week of her pregnancy. She was taken to the OR and a dilation and curettage (D&C) was
performed. There were no complications from the procedure. She will follow up with me in the
,office. She has had four antepartum visits during her pregnancy. What ICD-10-CM coding is
reported?
A. O03.9
B. O03.4
C. O03.1, Z3A.12
D. O03.9, Z3A.12 - B. O03.4
ICD-10-CM guidelines I.C.21.c.11 states category Z3A codes should not be assigned for
pregnancies with abortive outcomes (categories O00-O08)
The National Pressure Ulcer Advisory Panel defines the stages of pressure ulcers. What is
characteristic of a stage 3 pressure ulcer?
A. The skin is intact
B. May appear as a shallow, pinkish-red, basin-like wound
C. The bottom of the wound likely contains slough or dark, crusty dead tissue (eschar)
D. The ulcer has a crater-like appearance - D. The ulcer has a crater-like appearance
At stage 3, the ulcer is a deep wound:
*The loss of skin usually exposes some amount of fat
*The ulcer has a crater-like appearance
*The bottom of the wound may have some yellowish dead tissue (slough)
A 65-year old female sees her provider of constant pain in her right upper arm. She reports no
trauma but has been cleaning her basement and moving boxes. The patient was previously
diagnosed with. postmenopausal osteoporosis and the provider is concerned she may have a
fracture. The provider sends her to the outpatient radiology department for an x-ray which
reveals a fracture of the right humerus. What ICD-10-CM codes are reported?
, A. M80.021A
B. M80.821A
C. M80.021P
D. M80.022A - A. M80.021A
Subcategory M80.0---, Age related osteoporosis, includes postmenopausal osteoporosis
A 10 year old girl complains of left arm pain after falling while playing on the playground at
school. She was taken to Urgent care and the X-ray showed a Type 1 Salter-Harris fracture
(physeal) of the lower end of the left humerus. What ICD-10-CM code is reported for the
fracture?
A. S49.112A
B. S49.102A
C. S49.122A
D. S49.012A - A. S49.112A
The definition and function of a ligament is:
A. A tough cord that contracts to bend a body part at the joint
B. A tough cord that connect bone to bone and provides stability to joints
C. A tough cord that attaches muscle to bone that aids in movement
D. A tough cord that contracts to straighten a body part at the joint - B. A tough cord that
connect bone to bone and provides stability to joints
Ligaments, like tendons, are tough cords that connect bone to bone. Ligaments provide stability
to joints by holding the end of bones in place at the joint.
A 70 year old male see his provider for type 2 diabetes and chronic kidney disease. The kidney
disease progressed to stage 5 last year and he has been on dialysis since then. What ICD-10-CM
codes would be reported for. the patient's visit?